Med Surg Testbank, 2022 {Actual Questions and Answers} | 100% Correct

Med Surg Testbank, 2022 {Actual Questions and Answers} | 100% Correct 1. A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A. A scalp laceration oozing blood. B. Headache rated "10" on a 0-10 scale. C. • Serosanguineous nasal drainage. Correct D. Dizziness, nausea and transient confusion. An y nas al dis cha rge foll owing a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis. 2. A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide? A. "Start adoption proceedings immediately since obtaining an infant is very difficult." B. "Tell your friends and family so that they can help you." C. "Talkonly to other friends who are infertile since only they can help." D. • "Get involved with a support group. I will give you some names." Correct A sup por t gro up pro vid es a safe haven for the couple to share their feelings and experience, gain insight from others dealing with the same experience, and assure the couple that they are not alone in their situation. 3. When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include? A. There is a possibility of long bone pain. B. Permanent pigment changes to the breast may result. C. • Dry, itchy skin changes may occur. Correct D. A low-residue diet may be prescribed to reduce the likelihood of diarrhea. Side effects from radiation to the breast most often include temporary skin changes such as dryness, tenderness, redness, swelling, and pruritus. 4. A female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching the client, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? A. Hispanic women. B. Asian women. C. Caucasian women. D. • African American women. Correct Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs and has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In research studies it occurs more commonly in African American women (10-80 out of 100,000); compare to Caucasian women of the United States (8 out of 100,000). 5. A male client with a prostatic stent is preparing for discharge. Which information is most important for the nurse to provide the client prior to discharge? A. The client should not undergo magnetic resonance imaging. B. Increased frequency of assessment for prostatic cancer is needed. C. • The client should not be catheterized through the stent for at least three months. Correct D. Ongoing antibiotic therapy is needed for one year. A prostatic stent is a cylinder shape tube that is placed in the urethra to relieve prostatic pressure from an enlarged prostate and improve urine flo,w To prevent complications, the client should be cautioned against catheterization through the prostatic stent for three months after stent placement. 6. A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed? A. • "I know I will miss having sexual intercourse with my husband." Correct B . "I have asked my daughter to stay with me next week after I am discharged." C. "Well, I don't have to worry about getting pregnant anymore." D. "I can't wait to go on the cruise that I have planned for this summer." Further teaching is needed in response to the client's misunderstanding of not being able to have sexual intercourse after a hysterectomy. 7. The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? A. Procedure for feedings. B. Diameter of the tubes. C. • Method of insertion. Correct D. Location of the tubes. Th e bes t exp lan atio n of ho w a per cutaneous endoscopic gastrostomy (PEG) tube differs from a gastrostomy tube (GT) is by the method of insertion. GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is more commonly used as it does not require general anesthesia and is less invasive. Insertion is performed with endoscopic visualization through the esophagus into the stomach and then pulled through a small incision in the abdominal wall. It is held in place by a tiny plastic device called a "bumper" that holds the g tube in place with a small water-filled balloon securing it against the abdominal wall. 8. A client who is admitted to the coronary care unit with a myocardial infarction (Ml) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement? A. Prepare the client for an emergency echocardiography. B. • Notify the healthcare provider. Correct C . Increase the IV flow rate. D. Place the client in the supine position. Inc rea se d pul mo nar y co ngestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of Ml. The healthcare provider should be notified immediately for emergency interventions of this life-threatening complication. 9. What is the primary nursing problem for a client with asymptomatic primary syphilis? A. • Deficient knowledge. Correct B. Acute pain. C. Risk for injury. D. Sexual dysfunction. An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge of the disease pathophysiology. 10. Which client is at highest risk for compromised psychological adjustment after a hysterectomy? A. A 46-year-old woman with three children and a recent promotion at work. B. A 55-year-old woman with abnormal bleeding and pain for 3 years. C. A 29-year-old woman whose uterus ruptured after giving birth to her first child. Correct D. • A 62-year-old widow who has three friends who had uncomplicated hysterectomies. The client who is a primipara and is still in her childbearing years and is at highest risk for unresolved conflicts about the end of her childbearing opportunities. 11. The nurse is caring for a client receiving tamoxifen for the treatment of breast cancer. Which action should the nurse include in the client's plan of care? A. Encourage milk products to increase calcium intake. B. Increase fluid intake. C. Monitor sodium chloride intake. D. • Assist the client in coping with hot flashes. Correct Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so client education regarding menopausal-like symptoms should be included in the plan of care. 12. A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is70 beats per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per minute. Which action should the nurse implement next? A. Inform the healthcare provider. B. • Administer the medication. Correct C . Review the vital sign flowsheet. D. Reassess the apical heart rate. Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered since the client is not demonstrating any signs of toxicity. 13. Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? A. Intensity of pain. G u 8 . Ability to eat. i C. Unsteady gait. l D. • Respiratory effort. Correct l i n - B a rre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively. Heuther, Understanding Pathophysiology, 6th ed. p. 412 14. A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first? A. Prepare a warm enema solution for rectal instillation. B. Obtain a large bore needle for aspiration of the corpora cavernosa. C. • Notify the client's healthcare provider. Correct D. Document the finding in the client record. Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation in the penis, causing a reduction of blood flow and oxygenation to the penis, so the healthcare provider should be first notified immediately. The prescribed therapy may consist of noninvasive measures such as applying ice to the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa and giving pain medications. If noninvasive measures do not work, then needle aspiration of the corpora cavernosa is implemented by the healthcare provider. 15. A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? A. Sleep 6 to 8 hours. B. • Achieve a sense of control. Corre